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<br /> <br /> <br />~~E <br />~o.~ <br />0.&0 <br />f~!; <br />:SraEr <br />~~i <br />Ol_ <br />C"J ... <br />g~:! <br />::i Co-= <br />.-;t e Q <br />. gCi1 <br />Z - <br />nl . <br />erS' <br />i:; <br />~11l <br />~< <br /> <br />i <br /> <br />" ",:~j'~~'. .' ~~,;}~ :""";\,, .t., <br />~'" ~ .~'~.j ('. \~'..~~!.... \ d,~ <br />;" ~~. .r-..,.;.t.- <br />'NHEN THIS COPY CARRJD THE /fAI8ED SEAL OF THE NEBRASKA STAn... _. ~. .' '. ~ <br />"CERTIFIES THE BELOW TO BE A TRUE. COPY OF AN ORIGINAL REC --" . .. . ..' . . _ . . , <br />DEPARTMENT OF HEALTH, BUREAU OF VITAL STATISTICS, WHICH IS TH~~iti:. ~d/r". <br />VITAL RECORDS.=:..~:: :-"-.~~,~- ...... . '""'~':l2:.T!JJ!II <br />DATE OF ISSUANCE 'L,;o'~;'!" oq:",.~~",.,",~o:;/.. <br />AUG3 0 1996 200 8 0 5 0 8 5 %:o-~Lc. _" /~V~i" <br />ASS_".....,A_. f!M~],~/ <br />NEBRASKA . T-W::I1..ElY:?H <br />STATE OF NEBRASKA - DEPARTMENT OF HE~~"iii~'~ <br />BUREAU OF VITAL STATlSTICS",'=.;-~"C-C' <br />CERTIFICATE OF DEATH <br /> <br />LINCOLN, NEBRASKA <br /> <br />j'" <br /> <br />,. DECEDENT. NAME <br /> <br /> <br />FIRST <br /> <br />MIDDLE <br /> <br />LAST <br /> <br />2. SEX <br /> <br />(Monll>. Dar. YtHllr) <br /> <br />Doris <br />4, CITY AND STATE OF BIRTH (IIIICI;, U.S,A" MmtlcounIrJI) <br /> <br />Sa. AGE. <br />IV,..) <br />66 <br /> <br />1930 <br /> <br />Allen Nebraska <br />7. SOCIAL SECURTIV NUMBER <br /> <br />80. PLACE Of DEATH <br /> <br />HOSPITAL: [X,npolienI OTtiER: <br /> <br />o EROutpationt <br /> <br />0001. <br /> <br />80. COUNTY Of DEATH <br /> <br />o Nursing Home <br />o Residence <br />o Other ($pM:I!y, <br /> <br />508-32-8397 <br />.... FACILITY. Nome <br /> <br />(1I1ICI1f!$_. (JIw.lrHlond_) <br /> <br />B <br />Ie. 1rY. <br /> <br />an Memorial Hos i <br />OR lOCATION Of DEATH <br /> <br />1 <br /> <br /> <br />90. RESIDENCE - STATE <br /> <br />NoD <br /> <br />- coO\plolocll <br />CoIIAgo '''' '" 5'1 <br /> <br />MAIDEN SURNAME <br /> <br /> <br /> <br />210. CEMETERV OR CREMATORY . NAME <br /> <br />~1IufiaI <br />o C_ 0 Dona"'" <br /> <br />1141 <br /> <br />/ <br /> <br />Apfel Funeral. Heme <br /> <br />Grand Island, Nebraska <br /> <br />a, UNERAL HOME ADDRESS <br /> <br />lSTREET OR RF.D. NO" CITY OR TCHiN. STATE. ZIPI <br /> <br />Ail West 11 St. Wood River, Nebraska <br />21 IMMEOlATECAUSE C lENTERONL <br />PART .~ <br />I la' . CA y- y <br />DUE TO. OR AS A CONSEOUENCE OF: ~ <br /> <br />lb~~O.ORASAC~~E~ y~v <br /> <br />8883 <br /> <br /> <br />Interval between onaet and deatM <br /> <br />Interval b8twHn onset and death <br /> <br />~v't~Yv-h:o 11 <br /> <br />~.. _ on.... and d..", <br /> <br />-..,."--....,-., --- <br /> <br />fel <br />_T OTHE SIGNIFICANT CONDmONS . CondiIIone eonlrlbutlng to ... _'" but not ""ated <br />I <br /> <br />)( <br /> <br /> <br />... <br /> <br />:!eb. DATE OF INJURY (Mo.. Ooy. Yr.) 28<. HOUR OF INJURV <br /> <br />o Acektent 0 Undetermined <br />o Suicide 0 Pondlng 280, INJURV AT WORK <br />o _idol Investigotion V.. 0 No 0 <br />270. DATE OF DEATH (Mo" o.r. Yr.) <br /> <br />STREET OR R.F.D. NO. <br /> <br />26g. LOCATION <br /> <br />CITY OR TOWN <br /> <br />STATE <br /> <br />280. DATE SIGNED (Mo.. Ooy. Yf.) <br /> <br />281>. TIME OF DEATH <br /> <br /> <br />flll~ g 28e PRONOUNCED DEAD (Mo..Ooy, Yr) 28<1. PRONOUNCED DEAD (Hcurl <br /> <br /> <br /> <br />~ '-" 28iI On the basis Of .xamtnation andfOf' ir'wuIigation, In my opntOtl death occurrad 111 <br />"'" time, dale ond plaeo and due 10 "'" co"""',) '1Il1Id <br /> <br />M <br /> <br />M <br /> <br />UTE TO THE DEATH? <br />[]I UNKNCH-{N <br />31 NAME AND ADDRESS OF CERTIFIEII (PHYSICIAN, CORONER'S PHYSICIAN OR COUNTY ATTORNEYI (Ty(>> or Print/ <br />Kamran Ghalili H.D.l-stX)'So. 48 St. Suite 800., <br /> <br />32.. REGISTRAR I" <br /> <br />JO,b WAS CONSENT GRANTED' <br />o YES [XJ NO <br /> <br />Lincoln, Nebraska 68506 <br />32b. DATE FILED aJ1:ti~R2 3' 1996 <br /> <br />